Addressing Social Determinants of Health via Medicaid Managed Care Contracts and 1115 Demonstrations December 11, 2018
Agenda Welcome and Introductions About the Report Key Findings Federal Policy Recommendations Perspective from a Medicaid MCO 2
Today s Presenters Jennifer Babcock V.P., Medicaid Policy Dir., Strategic Operations ACAP Diana Crumley Program Officer CHCS Tricia McGinnis Senior Vice President CHCS Anne Kanyusik Yoakum Chief Executive Officer Hennepin Health 3
About the Report Research focused on:»requirements and incentives for MCOs related to social determinants of health (SDOH)»Managed care contracts/requests for proposals (RFPs) in 40 states»25 approved 1115 demonstrations Delivery System Reform Demonstrations, including Delivery System Reform Incentive Payment (DSRIP) demonstrations Demonstrations that implemented the following:»healthy behavior incentive programs»work/community engagement requirement»a managed care program 4
About the Report Excluded from our inventory:»common Medicaid benefits Home and community-based services Non-emergency medical transportation Health homes Targeted case management»requirements and incentives not in MCO contracts or 1115 demonstrations E.g., Minnesota s Integrated Health Partnership (IHP) RFPs 5
Advancing innovations in health care delivery for low-income Americans Overview of Key Findings 6 www.chcs.org @CHCShealth
Managed Care Contracts: Key Findings Growing focus on SDOH Most common references were in care coordination and management requirements Little detail on how MCOs can use existing authority to invest in SDOH interventions Few payment incentives explicitly linked to SDOH 7
Section 1115 Demonstrations: Key Findings Delivery system reform demonstrations focus on:»enhancing care coordination»building community partnerships to address SDOH»Payment incentives to advance these projects Healthy behavior incentives are not typically linked to SDOH Health plans in two states (Indiana and Arkansas) can help members meet eligibility requirements related to work and community engagement 8
Overview of Today s Discussion Systems and Partnerships»Care Coordination and Management»Quality Assessment and Performance Improvement Authority and Funding»Additional Services»MCO Payment Incentives»Value-based Payment 9
Advancing innovations in health care delivery for low-income Americans Systems and Partnerships Care Coordination and Management Quality Assessment and Performance Improvement 10 www.chcs.org @CHCShealth
11 WY WI WV WA VA VT UT TX TN SD SC RI PA OR OK OH ND NC NY NM NJ NH NV NE MT MO MS MN MI MA MD ME LA KY KS IA IN IL ID HI GA FL DC DE CT CO CA AR AZ AK AL Care Coordination and Management: 35 States KEY Contract 1115 Demonstration
Care Coordination and Management: Overview Screening»Initial screening for SDOH»Comprehensive assessment of those with special health care or long-term services and supports needs Care planning»risk stratification Linkages»Coordination with community and social support providers»referrals» Closing the loop 12 42 C.F.R. 438.208
Care Coordination and Management: State Examples Contract (Kansas) Focus: Social Determinants of Health and Independence Requires health risk assessment questions on domestic violence, housing, and employment Community service coordinators ensure linkages to community resources and support for education, employment, and housing 1115 (North Carolina) Opportunities for Health: Enhanced case management and other services Plan coordinates with Lead Pilot Entities, responsible for contracting with CBOs and social service agencies SDOH-related focus areas: housing, food, transportation, interpersonal violence 13
Quality Assessment and Performance Improvement: 13 States WA OR NV CA HI ID UT AZ AK MT WY CO NM ND MN SD WI NE IA IL KS MO OK AR MS TX LA NY MI PA OH IN WV VA KY NC TN SC AL GA FL ME VT NH MA RI CT NJ DE MD DC KEY 1115 Demonstration Contract 14
Quality Assessment and Performance Improvement: Overview Plan must have an ongoing comprehensive QAPI program»performance Improvement Projects (PIPs) Measurement of performance Implementation of interventions Evaluation Planning and initiation of activities increasing or sustaining improvement»performance measurement data»mechanisms to detect under- and over-utilization 15 42 C.F.R. 438.330
Quality Assessment and Performance Improvement: State Examples Contract (California) Requires the MCO to include proposed interventions that address health disparities in its quality improvement plans Contract (D.C.) Identify disparities, SDOH, and causes for disparities Develop a plan of action and a timeline to remediate identified SDOH and health disparities through targeted interventions and include this plan and timeline in the plan s QAPI program 16
Advancing innovations in health care delivery for low-income Americans Authority and Funding Additional Services MCO Payment Incentives Value-Based Payment 17 www.chcs.org @CHCShealth
18 WY WI WV WA VA VT UT TX TN SD SC RI PA OR OK OH ND NC NY NM NJ NH NV NE MT MO MS MN MI MA MD ME LA KY KS IA IN IL ID HI GA FL DC DE CT CO CA AR AZ AK AL Additional Services: 24 States KEY Contract 1115 Demonstration
Additional Services: Overview Value-added services»mco may voluntarily provide any service Activity that improves health care quality Incurred claims»cost not considered in the development of capitation rates In lieu of services»medically appropriate and cost effective substitute for the covered service or setting under the state plan»authorized and identified in the contract»cost considered in the development of capitation rates 19 42 C.F.R. 438.3(e)
Additional Services: State Examples Contract (Texas) Value-added services added by written amendment of the contract» Promotion of healthy lifestyles» Transportation services Case-by-case services at discretion of plan and not required to be part of the contract 1115 (Massachusetts) Accountable care organizations (ACOs) can pay for traditionally non-reimbursed flexible services to address healthrelated social needs» The state may provide a portion of flexible services funding directly to social service organizations to help them build infrastructure and capacity to better support ACOs in delivering flexible services 20
21 WY WI WV WA VA VT UT TX TN SD SC RI PA OR OK OH ND NC NY NM NJ NH NV NE MT MO MS MN MI MA MD ME LA KY KS IA IN IL ID HI GA FL DC DE CT CO CA AR AZ AK AL MCO Payment Incentives: 3 States KEY Contract 1115 Demonstration
MCO Payment Incentives: Overview SDOH-related targets in the following:»incentive arrangements MCO receives funds in addition to capitation rate, but may not receive more than 105% of the capitation rate»withhold arrangements Portion of capitation rate withheld and paid back if MCO meets targets in the contract»penalties Portion of capitation rate withheld for non-compliance with general operational requirements 22 42 C.F.R. 438.6
MCO Payment Incentives: State Example Contract (Michigan) Pay for performance bonus, tied to a 1% withhold arrangement Three SDOH-related bonuses» Population health management intervention» Low birth weight» Emergency department utilization Baseline analysis, intervention proposal, and intervention reporting 23
24 WY WI WV WA VA VT UT TX TN SD SC RI PA OR OK OH ND NC NY NM NJ NH NV NE MT MO MS MN MI MA MD ME LA KY KS IA IN IL ID HI GA FL DC DE CT CO CA AR AZ AK AL VBP Initiatives: 10 States KEY Contract 1115 Demonstration
VBP Initiatives: State Examples Contract (New Mexico) Care coordination is delegated, or partially delegated, to a specific provider as part of a VBP arrangement The MCO can share care coordination functions related to coordinating referrals and linking members to community services 1115 (Rhode Island) Accountable Entities (AEs) receive infrastructure incentive funds that can be used to develop capacity to address SDOH AEs report on the rate of screening for social needs. This measure factors into AE s quality score, which determines the AE s shared savings distribution 25
Advancing innovations in health care delivery for low-income Americans Recommendations for Federal Policymakers 26 www.chcs.org @CHCShealth
Systems and Partnerships: Recommendations Make it easier for vulnerable populations to access needed health services and care coordination Enhance agency collaboration at the federal level 27
Authority and Funding: Recommendations Provide additional guidance on addressing SDOH Approve 1115 demonstrations that test strategies to address SDOH Support outcomes-based payment for SDOH interventions 28
Visit CHCS.org to Download practical resources to improve the quality and costeffectiveness of Medicaid services Learn about cutting-edge efforts to improve care for Medicaid s highestneed, highest-cost beneficiaries Subscribe to CHCS e-mail, blog and social media updates to learn about new programs and resources Follow us on Twitter @CHCShealth 29
OUR WORK ADDRESSING THE SOCIAL DETERMINANTS OF HEALTH Anne Kanyusik Yoakum Chief Executive Officer
Overview State Policy Landscape Whom We Serve Hennepin Health Structure Initiatives Addressing the Social Determinants of Health 31
State Policy Landscape: Minnesota Department of Human Services (DHS) Procurement Prepaid Medical Assistance Plan (PMAP) and MinnesotaCare (BHP) are bid at least every five years In the most recent bid (for the 2016 plan year), DHS questions for Managed Care Organizations (MCOs) focused on the Social Determinants of Health Sample Question: Describe how the MCO currently and in the past has maximized the integration of primary health, behavioral health, Public Health, and Social Services. Provide a detailed description (and any data in support) of your current or developing internal infrastructure that helps maximize the integration of primary health, behavioral health, Public Health, and Social Services. 32
State Policy Landscape: Minnesota Department of Human Services (DHS) Accountable Health Model In February 2013 CMMI awarded Minnesota a State Innovation Model (SIM) testing grant of over $45 million Joint effort between the Minnesota Department of Health (MDH) and DHS Used to test new ways of delivering and paying for health care through the Minnesota Accountable Health Model framework Expand patient-centered, team-based care through service delivery and payment models that support integration of medical care, behavioral health, long-term care and community prevention services. Build on Minnesota's Integrated Health Partnerships (IHP) demonstration to adopt Accountable Care Organization (ACO)-style contracts with providers to better coordinate care 33
State Policy Landscape: Minnesota Department of Human Services (DHS) Accountable Health Model Goals accomplished by July 2017: 465,000 Minnesotans receive care through a Medicaid accountable care organization. 88 percent of organizations can engage in health information exchange. Integrated Health Partnerships surpassed the cost savings goal of $100 million, and as of 2016, have reached a cost savings of $212.8 million. 15 Accountable Communities for Health were established by 2015. 57 percent of providers are health care home or behavioral health home certified. 34
Whom We Serve: Hennepin County Most populous county with 1.2 million residents (one-fourth of Minnesota s population) Communities ranging from inner city neighborhoods to wealthy suburbs and rural areas Increasing poverty levels: 5% of families in 1999, up to 9% in 2010, with significant racial disparities 4% of white families in poverty 36% of black families in poverty 38% of Native American families in poverty Well-documented health disparities 35
36 Hennepin Health Structure: County System Levers for Health Improvement
37 Hennepin Health Structure: Accountable Health Model
Initiatives Addressing SDOH: Social Service Navigation Social workers and community health workers Facilitate access to services across Hennepin County SNAP Housing Chemical Dependency/Withdrawal Management Child Wellbeing and Protection Criminal Justice Emergency Cash Assistance Eligibility and Enrollment Supports Opportunities to coordinate with community partners, including health plans 38
Initiatives Addressing SDOH: Housing Development of indicator for persons experiencing homelessness through data analytics Individualized work with enrollees to: Identify short- and long-term housing goals Assist with applications for coordinated entry, Section 8, other housing programs Locate and submit required documentation Complete Professional Statement of Need 39
Initiatives Addressing SDOH: Redesigned Primary Care Clinics Multi-disciplinary team-based care Access Clinic and other intensive interventions for most complex Co-located medical, behavioral health, dental and social services Flexible access Extensions into the community $3,000.00 $2,000.00 $1,000.00 $0.00 Total Cost of Care/1000 Pre-Access Clinic Encounter Post-Access Clinic Encounter 40
Initiatives Addressing SDOH: New Enrollee Survey A regulatory requirement and an opportunity to connect Base survey from DHS, with an opportunity to modify Iterative, flexible process to develop future questions with broad input Challenges with difficult-toreach enrollees 41